Large hiatal hernia and iron deficiency anaemia: clinico-endoscopical findings

A Case of Cameron Lesions: An Overlooked Cause of Anemia in Patients With Gastrointestinal Bleeding and Hiatal Hernia

Cameron lesions are rare causes of upper gastrointestinal bleeding (UGIB). The lesions are linear erosions or ulcers that develop in the sac of a hiatal hernia, which often go unnoticed in the upper gastrointestinal system, and are a prevalent cause of anemia resulting from iron deficiency. Postponed treatment can result in severe consequences such as potentially fatal hemorrhaging. Here, we present a case of a young woman who presented to the emergency room with recurrent gastrointestinal bleeding and severe microcytic anemia. The chest X-ray revealed a partial intrathoracic stomach, and a large hiatal hernia was subsequently confirmed in the CT scan of the abdomen and pelvis. The esophagogastroduodenal endoscopy indicated Los Angeles Classification System grade A reflux esophagitis and an 8 cm hiatal hernia with multiple Cameron ulcers with pigmented material and chronic non-erosive gastritis. Biopsies of the gastric body and antrum showed Helicobacter pylori-associated chronic active gastritis and intestinal metaplasia. An esophagus biopsy showed squamous esophageal mucosa with mild chronic inflammation. The patient was treated with a transfusion of three units of red blood cells, iron replenishment, and pantoprazole infusion and underwent hiatal hernia repair with mesh and Toupet fundoplication without any complications. After that, the patient was discharged and scheduled for follow-up with general surgery at the outpatient clinic.

Cameron Lesions With Severe Anemia: A Case Report

This case presentation involves an elderly patient presenting with signs of severe anemia. Investigations lead to the detection of Cameron lesions within a large paraesophageal hiatus hernia (HH). These lesions have been described in the literature as being an incidental finding within the herniated stomach during endoscopy in patients with large HH who presented with microcytic hypochromic anemia. Progressive information regarding the relationship of this occurrence in patients with this specific type of anemia associated with HH has heightened physician awareness to rule out these lesions as a primary cause of chronic bleeding. There has been sporadic publication in literature stating Cameron lesions to be an unusual cause of chronic blood loss resulting in microcytic hypochromic anemia. Perhaps due to the lack of adequate emphasis on this frequent finding in elderly with HH in literature, textbooks are yet to include this condition as a differential diagnosis as one of the causes of upper GI bleeding (UGIB). This case study makes us ponder if this etiology is not rare after all and emphasizes the importance of considering Cameron lesions to be one of the established causes of chronic blood loss of upper GI origin in elderly with a large HH. Screening methods such as chest X-rays (CXR) could be used for early detection of the condition, and an esophagogastroduodenoscopy (EGD) for confirmation before requiring additional invasive investigations.

Resolution and recurrence of anemia following repair of paraesophageal hernias

BACKGROUND

Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed.

METHODS

We included patients who received a PEH repair between June 2019 and June 2020 and had 24 months of postoperative follow-up. Demographics and comorbidities were recorded. Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients were receiving iron supplementation. Anemia resolution was determined at 6 months post-op. Length of hospital stay, morbidity, and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively.

RESULTS

Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55 cm ± 2.77 vs. 4.34 cm ± 2.50; p < 0.001). Of 68 patients with available data by 6 months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 of whom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31 days ± 0.54 vs 2.33 days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166), gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05).

CONCLUSIONS

Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia is associated with a longer hospital stay and all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.

Paraesophageal hernia and iron deficiency anemia: Mechanisms, diagnostics and therapy

There is ample clinical evidence suggesting that the presence of large axial or paraesophageal hernias may lead to iron deficiency anemia. So-called Cameron lesions, as well as other small mucosa erosions, in the sliding area of these diaphragmatic hernias lead to invisible chronic blood loss and consequently to iron depletion. While the spectrum of symptoms in these patients is large, anemia is often not the only indication and typically not the primary indication for surgical correction of diaphragmatic hernias. Drug treatment with proton pump inhibitors and iron substitution can alleviate anemia, but this is not always successful. To exclude other possible bleeding sources in the gastrointestinal tract, a comprehensive diagnostic program is necessary and reviewed in this manuscript. Additionally, we discuss controversies in the surgical management of paraesophageal hernias.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65

Background

Iron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging.

Aims

The goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield.

Methods

A retrospective review of all CE studies at St. Paul's Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 μg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study.

Results

There were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn's therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, P = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, P = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, P = 0.012) were associated with a negative study.

Conclusions

These findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn's disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.

Cameron lesions: A still overlooked diagnosis. Case report and systematic review of literature

Cameron lesions are erosive-ulcerative alterations of gastric mucosa occurring in patients with large hiatal hernia, potentially causing gastrointestinal bleeding and iron deficiency anaemia. Diagnosis may be challenging, and not infrequently erosions are overlooked at endoscopy, so that repeated and unnecessary diagnostic procedures are performed, particularly in those patients with chronic anaemia. We described two peculiar cases of patients with iron deficiency anaemia in whom Cameron lesions were either overlooked or misinterpreted. By reviewing data of 22publications reporting endoscopic and clinical data of 140patients, we noted a large prevalence of females (75%). The most frequent presenting symptoms were anaemia (62%) and overt gastrointestinal bleeding (36%). Noteworthy, as many as 69% of patients underwent one or more previous upper endoscopy before diagnosis of Cameron lesion was achieved. Patients were mainly treated with proton pump inhibitor (PPI) therapy and iron supplementation. Moreover, endoscopic haemostasis was performed in 10% of case, blood transfusion was required in one third of cases, and a similar quote of patients underwent a surgical approach for hiatal hernia repair. The observation that as many as 60% patients were already receiving standard PPI therapy when diagnosis was performed would suggest that either long-term treatment with adequate dose PPI or surgical approach for hiatal hernia repair is required. In conclusion, Cameron lesion is still an overlooked diagnosis in patients with iron deficiency anaemia in whom a 5-9.2% prevalence has been reported.

Surgical Treatment of Paraesophageal Hernias: A Review

The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.

Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome

Cameron lesions, as defined by erosions and ulcerations at the diaphragmatic hiatus, are found in the setting of gastrointestinal (GI) bleeding in patients with a hiatus hernia (HH). The study aim was to determine the epidemiology and clinical manifestations of Cameron lesions. We performed a retrospective cohort study evaluating consecutive patients undergoing upper endoscopy over a 2-year period. Endoscopy reports were systematically reviewed to determine the presence or absence of Cameron lesions and HH. Inpatient and outpatient records were reviewed to determine prevalence, risk factors, and outcome of medical treatment of Cameron lesions. Of 8260 upper endoscopic examinations, 1306 (20.2%) reported an HH. When categorized by size, 65.6% of HH were small (<3 cm), 23.0% moderate (3-4.9 cm), and 11.4% were large (≥5 cm). Of these, 43 patients (mean age 65.2 years, 49% female) had Cameron lesions, with a prevalence of 3.3% in the presence of HH. Prevalence was highest with large HH (12.8%). On univariate analysis, large HH, frequent non-steroidal anti-inflammatory drug (NSAID) use, GI bleeding (both occult and overt), and nadir hemoglobin level were significantly greater with Cameron lesions compared with HH without Cameron lesions (P ≤ 0.03). Large HH size and NSAID use were identified as independent risk factors for Cameron lesions on multivariate logistic regression analysis. Cameron lesions are more prevalent in the setting of large HH and NSAID use, can be associated with GI bleeding, and can respond to medical management.

Transfusion-Dependent Anaemia: An Overlooked Complication of Paraoesophageal Hernias

Introduction. A paraoesophageal hernia (PH) may be one reason for iron-deficiency anaemia (IDA) but is often overlooked as a cause. We aimed to assess the incidence and resolution of transfusion-dependent IDA in patients presenting for hiatal hernia surgery. Methods. We analysed a prospective database of patients undergoing laparoscopic hiatal repair in order to identify patients with severe IDA requiring red cell/iron transfusion. Results. Of 138 patients with PH managed over a 4-year period, 7 patients (5.1%; M : F 2 : 5; median age 62 yrs (range 57-82)) with IDA requiring red cell/iron transfusion were identified. Preoperatively, 3/7 patients underwent repetitive and unnecessary diagnostic endoscopic investigations prior to surgery. Only 2/7 ever demonstrated gastric mucosal erosions (Cameron ulcers). All patients were cured from anaemia postoperatively. Discussion. PH is an important differential diagnosis in patients with IDA, even those with marked anaemia and no endoscopically identifiable mucosal lesions. Early recognition can avoid unnecessary additional diagnostic endoscopies. Laparoscopic repair is associated with low morbidity and results in resolution of anaemia.

Clinical characteristics and evaluation of patients with large hiatal hernia and Cameron lesions

OBJECTIVES

Cameron lesions are located at the neck of large hiatal hernias, and are associated with anemia or overt gastrointestinal (GI) bleeding. The aim of this study was to investigate the clinical and endoscopic properties of patients with Cameron lesions.

METHODS

Eighteen patients were diagnosed as having large hiatal hernia and Cameron lesions. Patients with Cameron lesions (n = 18) were compared to patients with large hiatal hernias without Cameron lesions (n = 26), by means of presenting symptoms and endoscopic findings.

RESULTS

The mean age of patients with Cameron lesions was significantly higher than patients without Cameron lesions (71.1 ± 11.63 vs 56.7 ± 17.4 years, P = 0.005). The ratio of female patients with Cameron lesions was higher compared to patients with large hiatal hernia without Cameron lesions (14/18 [77.7%] vs 12/26 [46.1%], P = 0.00). While 12 of 18 patients with Cameron lesions had overt GI bleeding, none of the patients with large hiatal hernia without Cameron lesions had signs of GI bleeding. Fifteen of 18 patients had ulcers in the hernia sac and the others had linear erosions. There was no significant difference between patients with and without Cameron lesions by means of hemoglobin levels (11.1 ± 2.20 vs 12.2 ± 2.5 g/dL, P = 0.157).

CONCLUSION

Most patients with large hiatal hernia and Cameron lesions presented with overt GI bleeding. Patients with Cameron lesions tend to be older females. In patients with anemia and GI bleeding, large hiatal hernia and Cameron erosions should also be considered.

Paraesophageal hernia: clinical presentation, evaluation, and management controversies

Practically, hiatal hernias are divided into sliding hiatal hernias (type I) and PEH (types II, III, or IV). Patients with PEH are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. Rarely, patients present with acute symptoms of hernia incarceration, such as severe epigastric pain and retching. A thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry. These investigations define the patient's anatomy, rule out other disease processes, and confirm the diagnosis. Operable symptomatic patients with PEH should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. Debate remains whether a transthoracic, transabdominal, or laparoscopic approach is best with good surgical outcomes being reported with all three techniques. Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long-term follow-up is required to determine whether the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice.